Changes in emotion regulation skills of school age children from the eyes of healthcare workers during the COVID‐19 pandemic in Turkey: A cross‐sectional study

Abstract Background and Aims While health workers were affected by the COVID‐19 pandemic on an individual and professional basis, their families and especially their children were directly or indirectly exposed to similar factors. This study aims to compare the emotion regulation competencies of school‐age children of healthcare workers in Turkey, before and during the COVID‐19 pandemic and to investigate their emotion regulation competencies during the pandemic in terms of care conditions, daily life activities and overall health. Methods This study used the purposeful sampling technique and was designed as a cross‐sectional and relational survey study. To conduct this study, permission was received from the Ministry of Health Directorate‐General for Health Services, COVID‐19 Research Evaluation Commission, and İzmir Kâtip Çelebi University Non‐Interventional Clinical Research Ethics Committee (Date/Decision no: 04.03.2021/0090). The data‐collection process was carried out online between March and July, 2021. A total of 106 healthcare workers who serve in pandemic clinics or fields participated in this study. In addition to the information forms prepared by the researchers of this study, the Emotion Regulation Scale (ERS), which was adapted into Turkish, was used. One‐way analysis of variance for independent samples was used for the analysis of variables, and paired samples t‐test was used to compare emotion regulation competencies before and during the pandemic. Results The children's total ERS scores increased during the pandemic (47.70 ± 8.35) when compared with their pre‐pandemic scores (44.86 ± 9.25), and furthermore this difference was found to be statistically significant (p = 0.000). The total mean ERS score of children with a healthcare worker parent increased significantly during the pandemic compared with the scores before the pandemic, which revealed that emotion regulation occurred at a lower level for these children. Conclusion The effect of the COVID‐19 pandemic on the emotion regulation competencies of children whose parents are healthcare workers is evident.


| INTRODUCTION
The new type of Coronavirus (COVID- 19) pandemic has unsettled the entire world over the past 2 years and has, primarily, confronted countries with a health crisis. Indeed, in the fight against the pandemic, healthcare workers have several primary concerns: access to the appropriate personal protection equipment, being contracted COVID-19 on duty, transmitting the disease to their families and colleagues, inability to afford personal and family expenses in case of getting infected, care of their children due to the closure of schools, the failure to meet personal and family needs as working hours and overtime requests increase, and lack of communication and up-to-date information. In addition to these concerns, reasons such as psychological burden, psychosocial pressure, burnout syndrome, discrimination and labeling, physical and psychological abuse, and violence have resulted in healthcare workers being more affected by the pandemic. [1][2][3] While healthcare workers are affected by the pandemic at an individual and professional base, their families and particularly their children are exposed to similar factors, either directly or indirectly.
Reasons such as their children's lack of understanding regarding the isolation precautions, the closure of centers that can provide caring services for children, the decrease in time spent together, the diversification and increase of children's support needs during the distance-education period, or the fear of parents' getting sick or losing them, has caused healthcare workers to go through a workfamily conflict and to experience more concerns regarding their children's health and development. [4][5][6] The literature highlights that the pandemic has deeply affected people's lives across the whole world and that measures such as isolation, contact limitations, and economic lockdown essentially threaten the mental health of children and adolescents. Moreover, it is reported that the daily routines such as sleeping, nutrition, playing, amd so forth, and of the mental health of both parents and children have been negatively affected by the pandemic process. During the pandemic, anxiety, lack of peer interaction, and decrease in opportunities for emotion regulation (adjustment) were among the main concerns of experts. 5 Emotion regulation is considered an essential source for children's development, particularly when facing difficulties, and several comparative studies have been conducted on this issue. 7 In keeping with a perspective that conceptualizes development as the increasing diversification and hierarchical integration of biological and psychological systems, it is highlighted that children's emotion regulation competencies become more complicated and integrated during preschool and primary school years. Researchers underline the need to measure the emotion regulation competency in a more significant number of situations of increasing difference to better understand this complex development process. 8 Many different studies have been undertaken to depict the situation in Turkey, on healthcare personnels' physical and psychological wellness during the pandemic, some of which are revisions or letters to the editor and some of which are original research papers. 4,6,[9][10][11][12][13][14][15] However, only a few studies that inform about changes in children's physical, psychological, and developmental states were encountered in the related Turkish literature. [16][17][18][19] It is of critical importance to know the implicit consequences of the pandemic on children to support children and families in a more qualified way. In this regard, considering the fact that emotion regulation is the leading dimension of psychological health, this study investigated the emotion regulation competency of children of healthcare workers in terms of various variables during the COVID-19 pandemic.

| Study design and duration
The study was designed online as a cross-sectional and relational survey study using the sampling technique for research purposes.
Considering the pandemic conditions, all data were collected online between March and July 2021.

| Participants
The sample size was measured using G*power 3.1.9.2 with α = 0.05, power (1−β) = 0.80 and the effect size is 0.3 and the sample size obtained was 90. 20 The criteria for inclusion in the study are being a health worker working in public or private health institutions, having worked or working in pandemic clinics and the field, having children in the school age group (6−12 years old), and volunteering to participate in the study. However, the exclusion criteria from the study were not working in pandemic clinics and the field and having a child out of school age. The sample included 106 healthcare professionals who gave consent to participate in the study, worked in pandemic clinics/ field and had school-age children, and information was obtained from healthcare professionals about the emotional regulation of schoolage children before and during the pandemic. The following data-collection tools were used in the present study: Demographic Information Form for Parent was used to gather information on the demographics of healthcare worker parents; the Information Form for Parent's Working Conditions was used to collect information on the working conditions of the parents, and the Information Form for Parents' School-Age Children of Parent was used to gather information regarding the care conditions and daily life activities of parents of children aged 6-12 years. The researchers of the present study created these forms for use within the scope of this study.

| Data collection tools
The ERS was used to determine the children's emotion regulation competencies before and during the pandemic.

| ERS
The Scale, originally titled Emotion Regulation Checklist, was developed by Shields and Cicchetti, was used to determine the children's emotion regulation competencies before and during the pandemic. 8,21 Kapçı et al. adapted this Scale into Turkish, and permission was obtained to use the Scale for the present study. 21 The Scale can be filled out by a child's mother, father, and teacher, as well as any adult who knows the child. The Scale comprises 24 4-point Likert-type items indicating never "1," occasionally "2," frequently "3," and almost always the Scale is highly reliable in its evaluation. Consequently, the researchers proved that the Scale could be used to evaluate the emotion regulation competencies of 6-12-year-old children. 21 A high total score obtained from the scale indicates that the child's emotion regulation is at low level.
A high first factor (Instability/Negativity) score indicates that the child is unable to regulate emotions, and a high second-factor score (Emotion Regulation) indicates that the child has a good level of emotion regulation. 21  skewness coefficients were used (±1). One-way analysis of variance for Independent Samples was used for the analysis of the variables that were found to be normally distributed, and related samples t-test was used to compare the children's emotion regulation competencies before and during the pandemic. Throughout the study, values p < 0.05 were considered to be statistically significant.

| RESULTS
As a result of post hoc analysis, the power was determined as 86% for 106 participants.
The sociodemographic information of the participants and their children is presented in Table 1     However, the difference between these groups was not significant. A different study that investigated the anxiety levels and sleeping problems of children of healthcare workers who had COVID-19 reported that some anxiety problems, independent of COVID-19, had been observed in these children; the same study also reported that parents' being apart from home during the pandemic is a predictor of children's sleeping disorders. 19 This study also determined that there is a positive correlation between the anxiety of healthcare workers and their children; this correlation may explain the negative changes observed in children's daily life activities in the present study. 18 In a study that compared the anxiety and depression levels of children (aged 9-17 years) of healthcare workers with those of nonhealthcare workers' children (also aged 9-17 years) in the first year of the pandemic, no significant difference was detected between the two groups in terms of their levels of depression levels.
However, the study also found a significant difference between the two groups of children regarding anxiety levels, with the children whose parents were healthcare workers experiencing more anxiety.
These findings are critical because they show that children whose parents work in highly risky settings are at greater risk compared with other children. 16 During the pandemic, healthcare workers who assumed the responsibility of protecting and curing society as well as themselves and their families needed help in supporting their children. According to a study on the telehealth system that was established to provide psychiatric assistance to healthcare workers in Turkey, it was determined that one-quarter of the users of the system asked for support in taking care of their children. 17 The specialists in the aforementioned study stated that they were particularly concerned that single parents and parents who are at the front lines of the In a study conducted in Italy, it was stated that more than 30% of the adults and children in the pandemic area were at greater risk of posttraumatic stress disorder and that this rate is higher for healthcare workers directly involved in COVID-19 care and their children. 26 Parents who could work from home experienced pandemic-based stress and some difficulties in providing full-time attentive childcare.
In addition, due to opportunities missed concerning education and interaction with other children, the inability to present stimuli in a desired quantity and quality that support developmental and play environments has caused parents to raise concerns regarding their  writingreview and editing. Elif Oral: Writingreview and editing.

ACKNOWLEDGEMENT
We would like to thank those healthcare workers who continue to devotedly serve in the fight against the pandemic and as well as the families of these healthcare workers. No funding was used to support this research and/or the preparation of the manuscript.

CONFLICT OF INTEREST
The authors declare no conflict of interest.

DATA AVAILABILITY STATEMENT
The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions. All authors have read and approved the final version of the manuscript. Bedriye Tugba Karaaslan had full access to all of the data in this study and takes complete responsibility for the integrity of the data and the accuracy of the data analysis.

ETHICS STATEMENT
Before starting the implementation of the study, necessary permis-

TRANSPARENCY STATEMENT
The lead author Bedriye Tuğba Karaaslan affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.